Building on the lecture I gave (and uploaded) "Palliative Care: what every primary care doctor should know" I built this talk. It is geared for 1st year medical students who are learning anatomy, physiology, and perhaps some pharmacology and pathophysiology.
In this talk, I do not explicitly address hospice care - as that was provided in an online chapter for students at UMass. I will later upload another slide set on that topic.
I hope you enjoy it.
FYI- the link to the youtube video: http://www.youtube.com/watch?v=XHtHXGhTIC4
Link to PDF of the slide show: https://files.me.com/s.mak/8fzat6
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Palliative Care: What every medical student needs to know
1. Palliative Care:
What every 1st year medical
student needs to know
Suzana Makowski, MD MMM FACP FAAHPM
Assistant Professor of Medicine
Slide presentation for 1st year medical students in the Cancer Concepts Course at
UMass Medical School
2. • What is Palliative Care?
• What is Hospice?
• How do we care for the dying?
Overview
3. “an approach that improves
the quality of life of
patients and their families
facing the problems
associated with life-
threatening illness, through
the prevention and relief of
suffering by means of early
identification and
impeccable assessment and
treatment of pain and other
problems, physical, psycho
social and spiritual.”
WHO definition
Palliative Care
4. • ―It’s not about killing
Granny; it’s about
keeping Granny alive as
long as possible — with
the best quality of life.‖
- Diane Meier, NYTimes
Why discuss palliative care?
11. • 50 to 90 percent of oncology inpatients report
breakthrough pain
• 35 percent of community based oncology practices
patients report breakthrough pain
• 1 in 3 patients with active cancer report pain
• 3 out of 4 of patients with advanced cancer report pain
Cancer pain prevalence
12. • Bone metastases
• Visceral metastases
• Immobility
• Neuropathic pain
• Soft tissue
• Constipation
• Esophagitis
• Lymphedema
• Muscle cramps
• Chronic postoperative scar
• Adapted from Twycross R, Harcourt J, Bergl S: A survey of pain in patients with
advanced cancer. J Pain Symptom Manage 1996;12:273-282.
Causes of cancer pain
13. Physical Emotional Existential
• Increased catabolic demands: Depression Suffering –
poor wound healing, weakness, muscle Anxiety ―why me?‖
breakdown Decreased
• Decreased limb movement: intimacy
Suicidality
increased risk of DVT/PE
• Respiratory effects:
shallow breathing, tachypnea, cough
suppression increasing risk of pneumonia and
atelectasis
• Sodium and water retention Decreased
gastrointestinal mobility
• Tachycardia and elevated blood pressure
• Decreased functional status
• Increased chronic pain
Effects of under treated pain
15. Category Cause Symptom Examples
Physiologic Brief exposure to a Rapid yet brief pain Touching a pin or hot
noxious stimulus perception object
Somatic or visceral tissue Moderate to severe pain, Surgical pain,
Nociceptive/infla
injury with mediators described as crushing or traumatic pain, sickle
mmatory
having an impact on stabbing cell crisis
intact nervous tissue
Damage or dysfunction Severe lancinating,
Neuropathy, CRPS.
Neuropathic of peripheral nerves or burning or electrical
Postherpetic Neuralgia
CNS shock like pain
Combinations of Low back pain, back
Combined somatic and
Mixed symptoms; soft tissue plus surgery pain
nervous tissue injury
radicular pain
Pain Quality
16. WHO pain relief ladder
Non-opioid = acetaminophen, NSAID, neuroleptic • Adjuvant = steroid, etc.
17. • Mrs. Dolores de Barriga is a 67 year old Peruvian
immigrant with metastatic colon cancer, who has
increasing abdominal pain. She has a colostomy and has
regular bowel movements.
• Her current pain regimen is:
• Morphine ER 15mg twice daily
• Percocet (oxycodone 5mg + acetaminophen 500mg) – 1-2
tablets every 4 hours as needed. She has been taking 2
tablets every 4 hours for the last week.
Why is this dangerous?
19. Short-acting Long-acting
• Hydrocodone/APAP
• Transdermal fentanyl
• Oxycodone +/- APAP
• methadone
• Morphine
• morphine ER
• Hydromorphone
• oxycodone ER
• Oral transmucosal fentanyl
• Cmax ~ 45 min
Cmax and T1/2 vary based on
• T1/2 ~ 2-4 hours
formulation and drug
• Except fentanyl
Opioid Pharmacology
20. What is the half life (range) for opioids?
• 2-4 hours
How many half lives to get to steady state?
• 4-5
What do you base your scheduled dosing on: Cmax or C?
• t1/2
What do you base your breakthrough dosing on: Cmax or t1/2?
• Cmax
A quick quiz
21. • Follow first order kinetics
• Conjugated by liver
• 90-95% excreted in urine
• Dehydration, renal failure, severe hepatic failure
• Decrease interval/dosing size Why is morphine
contraindicated in
• If oliguria/anuria renal failure?
• STOP routine dosing (basal rate) of morphine
• Use ONLY PRN
Opioid pharmacology
(except methadone)
22. • Morphine 3-glucoronide
• Not an opioid agonist
• Stimulates the GABA/glycinergic
system
• Can cause neuro-excitation –
agitation, hyperalgesia, myoclonus, se
izures.
• Morphine 6-glucoronide
• Active metabolite that acts as an
opioid agonist – especially against the
mu-opioid receptor
Morphine metabolites
build-up disproportionately in renal failure
23. Optimal symptom • Same ―rules‖ apply
management • CMO ≠ Continuous Morphine Only
Personalized • Goals of care based
healthcare • Not problem based
Whole-person • Bio-psycho-social-spiritual approach
care • Interdisciplinary
Palliative Care
24. Myth: Palliative care = “no more treatment”
We assess the values & goals of a patient, designing care around them
25.
26. On an average day in Massachusetts:
1
A few infant
childre
n 144
people die
Some
Most middle
over 75 aged
Massachusetts facts
29. • In the United States, hospice is a form of care provided to
patients whose life expectancy is 6 months or less.
• It is generally provided in the patient’s home, but can be
received in nursing homes, hospices houses, etc.
• It is a Medicare benefit (that many other insurances
cover)
• Its approach is to help people live as well as possible, for
the time they have left: alleviating symptoms, reaching
goals, supporting family, addressing spiritual needs.
• As long as a person’s prognosis remains 6 months, the
benefit does not run out.
• A patient may be ―full code‖, ―DNR/DNI‖ – according to
their goals and preferences on hospice.
Hospice care:
1 way to help stay home
30. Hospice Home Palliative (VN)
Requires Prognosis <6months Home-bound only
(Not required: code status, Must show improvement
primary caregiver)
Services Nurse, social worker, Nurse, PT/OT
chaplain, volunteer, home
health aide
DME* All covered Not covered
Meds Covered if associated with Not covered
dx
Hours 24/7 Regular business hours
Other Bereavement for family up None
to 13 months after death
*DME = durable medical equipment (bed, oxygen, commode, etc.)
34. • Until recently, only 10% of medical students had any
courses on how to care for dying patients.
• Practicing non-abandonment is tough when we don’t
know what to do.
• Know the signs and symptoms of dying and means to
treat them.
• Address fears, anticipate problems
“
• Sir William Osler:
“
To cure sometimes, to alleviate
often, to comfort always.
What we know
35. • Cancer Cachexia/Anorexia
• Metabolic demands of cancer outpace that of the body
• Malnutrition: protein and fat depletion
• Loss of intravascular oncotic (osmotic) pressure due to low
albumin and other proteins
• ―third spacing‖ of fluid to abdomen, lungs, subcutaneous
tissue
How does this differ from starvation?
Physiology of dying with cancer
36. • Decreased perfusion of brain
• Increased fatigue, somnolence Signs/Symptoms
• Poor control of bowel and bladder
• Change in respiratory pattern (late) • Decreased
energy
• Decreased reflexes, including gag and
• Increased sleep
swallow – leads to pooling of saliva in back • Respiratory
of throat pattern changes
• Decreased cardiac output • ―Terminal
• Poor peripheral perfusion: skin breakdown secretions‖
• Skin breakdown
• Decreased perfusion of the kidneys (low • Peripheral
intravascular volume/pressure, low cardiac ―mottling‖
output) leads to pre-renal azotemia
Physiology of dying
38. Pan = all
Cyto = cell (usually referring to blood cells)
• Dolores returns Penia = poverty
• she is now pancytopenic
due to bone marrow
involvement
• plts now 5,000/mcl,
• Hct 12%,
• WBC 2,000/mcl
What signs/symptoms might she experience?
39. • Brain
• Seizures, brain stem herniation What to do once you can no
longer transfuse blood? – Be
• Mucosa prepared
• Nose bleeds, vaginal bleeds
• For bleeds you can see:
• Lungs dark blue towels, surgicel
• Dyspnea, hemoptysis or topical thrombin for
nose/mucosa
• GI tract • Benzodiazepam for
seizures
• Hematemesis, aspiration of
• Opioid and benzo of
blood, bloody stool phenobarbitol for
• Retroperitoneal hemoptysis, pain, etc.
• Back pain
Where could she bleed?
42. • Most physicians practice Palliative Care every day
• Palliative care includes any care that enhances quality of
life (QOL) – regardless of its effect on longevity (it may
prolong life!)
• Prognostication is hard, but important. It helps patients
plan, achieve goals that they can reach.
• Palliative care can help patients at any stage of a serious
illness, while hospice is available for patients whose
prognosis is on average 6 months.
Summary
43. • EPEC (Education on Palliative & End-of-Life Care)
• Lois Green Learning Community
www.loisgreenlearningcommunity.org
• Get Palliative: www.getpalliativecare.org
• Pallimed Connect
How to learn more
Notas do Editor
My story:This is April. I met her in my clinic in Billings. She first came to me for symptom management of her metastatic breast cancer. She also wanted to know what to eat, how to keep her function high. She was curious about our “Hope for Tomorrow” program for cancer patients. She and her husband joined – and participated in yoga, cooking class, groups support with mindfulness. This picture was taken 6 weeks before she died. 1- my patients found me. They wanted someone to listen, to manage their symptoms while someone else battled their illness, someone to help make plan “b” and to address their whole person.2- I realized I was not as good at managing symptoms for patients as I thought I was. I thought Zofran was the be-all-and-end-all for nausea. I was wrong. I thought opioids were taught in residency. I was wrong. I thought at end of life, all meds, except morphine and ativan were given, generally speaking. I thought I knew how to tell who was dying.3- I liked tending to the seriously ill. I was intrigued and curious about their ability to live so very fully. To find joy. To talk about difficult things and to find meaning. I often found them to be more alive than many. They showed me what hope really meant.
Everybody dies.Cancer continues to be one of the leading causes of death.Good symptom management, coordination of care and help patients live better and longer.The obligation of the physician is to alleviate suffering.
I used to think that this was the model. We “treat” and then we help people die peacefully. I was wrong.
It is more like this… but I still don’t fully agree with this picture. After all – it is usually symptoms (except when there are screens) that bring our patients to us: dyspnea, nausea, pain… But anyway, curative and palliative therapies tend to work hand in hand. You do this every day, and better than most.
The paradigm of palliative care is to approach the person from a multi-dimensional model. Biopsychosocialspiritual was the way I learned it in medical school. Mind-body-spirit might be the way integrative medicine physicians call it. Good care, is another name. Most of us tend to 1-6 with our patients all the time. Even in palliative care, 7 and 8 are often not in the mix.
Nurse with metastatic breastca – loves to golf and to work 12 hour shifts.Hip pain was limiting her activity, however. How to respond?Intrathecal pump – coordinated between neurosurgery, anesthesia, and palliative care
LL is a 57 yo woman with metastatic pancreatic cancer, diagnosed 5 years ago.She now presents to hospital with:Pain (rectal)Breathlessness (pleural effusion and pericardial effusion)Anorexia, weight lossFatigueHer goals have always been to live as long as possible, to see her children grow, and in the words of USC, to “fight on!”Pain: Opioids, steroids, plus: nerve block – impar or sub-gastric ganglion.Dyspnea: Opioids, chlorpromazine, plus: thoracentesis, pericardial window
We want to offer hope… so how can we?Story: 21 year old, dying of adenocarcinoma – Crohn’s – bowel obstructionAfter he was told that the cancer was found everywhere, there there was no more curative treatment available…He asked:Will I have to stay in the hospital or can I get home to see my dog? – He had a 4 month old golden retriever. He didn’t want to see her in hospital – just at home.He is at home now. His brother brought him his golden retriever home. She now visits daily – when he is up for it.He asked his hospice nurse: Will I see my best friend before I die? Where is she? In Germany. Well, we shall see then.They found an agency to help. She flew home 3 days later to spend time with him.I asked him if he had any questions… He asked:When will the bad pain start again? – I answered, If I do my job well, if the hospice nurses do theirs well, it will never start again.
Everybody dies.Cancer continues to be one of the leading causes of death.Good symptom management, coordination of care and help patients live better and longer.The obligation of the physician is to alleviate suffering.
You can help them secure their hopes… for how they wish to be cared for at the end of life…
And avoid what most of us will end up facing
Everybody dies.Cancer continues to be one of the leading causes of death.Good symptom management, coordination of care and help patients live better and longer.The obligation of the physician is to alleviate suffering.
Everybody dies.Cancer continues to be one of the leading causes of death.Good symptom management, coordination of care and help patients live better and longer.The obligation of the physician is to alleviate suffering.
Help our way… Engage with grace – the one slide project – promoted over ThanksgivingNational healthcare decisions day – In April – this year, this weekend. Perhaps we could coordinate something for next year?
Everybody dies.Cancer continues to be one of the leading causes of death.Good symptom management, coordination of care and help patients live better and longer.The obligation of the physician is to alleviate suffering.